Indications for and outcomes of cholecystectomy: a comparison of the pre and postlaparoscopic eras.

PURPOSE: Examine changing patient characteristics and surgical outcomes for patients undergoing cholecystectomy at five community hospitals in 1989 and 1993. PROCEDURES: In a retrospective chart review, data were gathered regarding gallstone disease severity, type of admission, patient age, number of comorbidities, American Society of Anesthesiologists (ASA) Physical Status Classification, length of stay, and multiple outcomes of surgery. MAIN FINDINGS: The volume of nonincidental cholecystectomies increased 26%, from 1611 in 1989 to 2031 in 1993. Nearly all of the increase occurred among patients with uncomplicated cholelithiasis and with elective admissions. In 1993, lengths of stay were significantly shorter and percentages of complications were significantly lower for infectious, cardiac, pulmonary, and gastrointestinal complications when controlling for patient case-mix characteristics. There were more major intraoperative complications (unintended wounds or injuries to the common bile duct, bowel, blood vessel(s), or other organs) in 1993. CONCLUSIONS: Different types of patients underwent cholecystectomy in 1993 compared with patients in 1989, which supports the hypothesis of changing thresholds. Statements supporting the safety of cholecystectomy in the laparoscopic era were borne out when controlling for differences in patient characteristics.

What predicts gastroenterologists' and surgeons' diagnosis and management of common bile duct stones?

BACKGROUND: Because the literature suggests numerous indicators of common bile duct stones, we undertook a systematic assessment of physicians' judgments of the clinical utility of eight indicators: patient age, history of jaundice, history of pancreatitis, levels of serum alanine aminotransferase, alkaline phosphatase, amylase, and total bilirubin, and common bile duct diameter on ultrasonography. METHODS: Random samples of 1500 gastroenterologists and 1500 surgeons were sent a survey asking them to indicate the importance of each potential indicator of common bile duct stones, the likelihood of common bile duct stones for each of nine clinical vignettes, and whether they would order a preoperative ERCP. An abbreviated survey was sent to nonrespondents. RESULTS: Although there was substantial variation in the importances assigned to each indicator, the most important indicators were serum total bilirubin and diameter of common bile duct on ultrasound. The best predictors of the decision to order an ERCP were perceived likelihood of stones and specialty. The average threshold for ordering an ERCP was 37%. Respondents did not differ from nonrespondents in the perceived importance of the eight indicators. CONCLUSIONS: The substantial variation among gastroenterologists and surgeons regarding the optimal approach to common bile duct stones has clinical implications. Patients will receive varying recommendations for care, depending on whom they see.

Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis.

OBJECTIVE: The purpose of this study was to perform a meta-analysis of large laparoscopic cholecystectomy case-series and compare results concerning complications, particularly bile duct injury, to those reported in open cholecystectomy case-series. SUMMARY BACKGROUND DATA: Since the introduction of laparoscopic cholecystectomy in the United States, hundreds of reports about the technique have been published, many including statements about the advantages of laparoscopic cholecystectomy compared with those of open cholecystectomy. There is an unevenness in scope and quality of the studies. Nevertheless, enough data have accumulated from large series to permit analyses of data regarding some of the most important issues. METHODS: Articles identified via a MEDLINE (the National Library of Medicine's computerized database) search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes of cholecystectomy were abstracted and summarized across studies. RESULTS: Outcomes of laparoscopic cholecystectomy are examined for 78,747 patients reported on in 98 studies and compared with outcomes of open cholecystectomy for 12,973 patients reported on in 28 studies. Laparoscopic cholecystectomy appears to have a higher common bile duct injury rate and a lower mortality rate. Estimated rates of other types of complications after laparoscopic cholecystectomy generally were low. Most conversions followed operative discoveries (e.g., dense adhesions) and were not the result of injury. CONCLUSIONS: There is wide variability in the amount and type of data reported within any single study, and patient populations may not be comparable across studies. Except for a higher common bile duct injury rate, laparoscopic cholecystectomy appears to be at least as safe a procedure as that of open cholecystectomy.

Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis.

BACKGROUND: The decision of whether or not to investigate for common bile duct stones before cholecystectomy utilizes clinical, laboratory, and radiologic information (indicators). There is tremendous individual variation among clinicians in the criteria used for making this decision. Our aim was to perform a meta-analysis of published data to estimate the performance characteristics of the most commonly used preoperative indicators of common bile duct stones. METHODS: Using predetermined exclusion criteria, we selected articles from a MEDLINE search and bibliographic review. Weighted averages were used to determine summary sensitivity, specificity, and positive and negative likelihood ratios for each indicator for stones. RESULTS: From 2221 citations identified, 22 studies met inclusion criteria. The 10 indicators examined were reported in a common fashion in three or more articles, and could be assessed preoperatively. Seven exhibited a specificity greater than 90%. Indicators with positive likelihood ratios of 10 or above were cholangitis, preoperative jaundice, and ultrasound evidence of common bile duct stones. Positive likelihood ratios for dilated common bile duct on ultrasound, hyperbilirubinemia, and jaundice ranged from almost 4 to almost 7. Elevated levels of alkaline phosphatase, pancreatitis, cholecystitis, and hyperamylasemia exhibited positive likelihood ratios of less than 3. CONCLUSIONS: This meta-analysis has identified indicators for duct stones and ranked them according to likelihood ratios. These findings can be applied as guidelines for whether to investigate for duct stones before cholecystectomy.

Increased ERCP rate following the introduction of laparoscopic cholecystectomy.

Over the past 5 years there has been a remarkable change in the manner in which symptomatic gallstones are surgically managed. In this study we reviewed the experience of a large HMO to determine the relationship between the rate of increase of ERCP and that of cholecystectomy. All individuals enrolled in US Healthcare's HMO-PA, in the region of southeastern Pennsylvania from 1988 through 1993, were included in the analysis. Using the HMO claims database, patients who underwent an open or laparoscopic cholecystectomy during the study period were identified. We then identified those patients who had a pre- or post- operative ERCP. Over the study period, there has been a substantial increase in cholecystectomies per 1000 members-from 1.37 in 1988 to 2.16 (p < 0.0001) in 1993. In our study population there were 1261 ERCPs performed in 979 patients with an average of 1.3 ERCPs per patient during the study period. The ERCP rate per 1000 members has increased from 0.16 to 0.56 (p < 0.0001) from 1988 to 1993, at the same time that the cholecystectomy rate was substantially increasing. The correlation for the ERCP and cholecystectomy rates from 1988 to 1993 was 0.994 (p < 0.0001). Since the introduction of laparoscopic cholecystectomy in 1989-1990, many more ERCPs are now being performed. It is necessary to determine the implications related to the rapid diffusion of laparoscopic cholecystectomy, including the effect that this technology has had on other older and stable technologies such as ERCP. Our results describe the dramatic effect that laparoscopic cholecystectomy has had on the utilization of ERCPs.

The effect of telemetry on urban prehospital cardiac care.

A three-year, controlled trial of the use of telemetry in the prehospital care of cardiac patients was conducted in a major metropolitan area. Five of the ten paramedic squads in the city used telemetry; the other five squads did not. We studied the effect of telemetry on the following: paramedics' abilities to recognize ECGs in a written test; paramedics' abilities to identify ECG arrhythmias in the field; length of time spent by paramedics in the field; survival rates of patients with ventricular fibrillation (VF) cared for by paramedics; abilities of base station physicians to interpret telemetered ECGs; and attitudes of paramedics toward using telemetry. Telemetry was not found to affect the abilities of paramedics to read ECGs in either test or field situations. Paramedics who used telemetry spent more time in the field with their patients than did paramedics who did not use telemetry (P less than .02). We found no statistically significant effect of telemetry on survival rates of VF patients. Using matched ECGs, readings by base station physicians were found to be more accurate than were those by paramedics (P less than .01). Paramedics overwhelmingly reported that telemetry did not help them to save patients' lives, but that it did help them to treat patients with certain arrhythmias. The results suggest that telemetry may not improve either paramedics' abilities to identify arrhythmias or prehospital care for all cardiac patients. The implications for emergency services researchers are discussed.

[Estimation of partition coefficients using membrane electrodes]. / Zur Ermittlung der Verteilungskoeffizienten mit Membranelektroden.

The applicability of liquid membrane electrodes for estimation of partition coefficients is demonstrated. The correlation of selectivity coefficients of electrodes based on tricaprylmethylammonium-ion pairs with the octanol/water partition coefficients is demonstrated for several barbiturates. It is statistically significant and allows a simple estimation of partition coefficients.

Clinical algorithms for prehospital cardiac care.

Algorithms for the prehospital management of cardiac arrhythmias were developed and their use by and value to paramedics evaluated. The algorithms, in booklet form, were distributed to half of the Philadelphia paramedic platoons; paramedics in the other platoons followed a narrative protocol that reflected identical contents. An arrhythmia recognition test given 18 months after the algorithm booklets were introduced showed that paramedics who received the booklets scored significantly higher in identifying life-threatening arrhythmias (p = 0.029) than did their counterparts without the booklets. Survival data for 459 patients in ventricular fibrillation treated by paramedics were collected 1 year before and 7 months after the introduction of the algorithm booklets. The paramedics using the algorithms improved their survival rate from 11.25 to 15.1 per cent, while the survival rate for patients treated by paramedics using the narrative protocols decreased from 12.4 to 7.7 per cent. The likelihood of obtaining a ratio of survival odds of this magnitude when there is no true difference is 0.092. Time-to-death was significantly different (p = 0.04) for the two groups of patients. Thus, the use of algorithm booklets as an inexpensive educational aid for paramedics is recommended.

Impact of prehospital cardiac algorithms on ventricular fibrillation survival rates.

To determine the value of algorithms in the field, a set of cardiac clinical algorithms was developed for and tested by the City of Philadelphia paramedics. A controlled test was carried out by revising the narrative standard operating procedure to reflect algorithm content and giving the algorithms, in pocket-size booklet form, to half the Fire Rescue platoons (43 men). Baseline data included paramedics' characteristics, arrhythmia recognition and management test scores, and data on the number of patients who were discharged alive from the hospital following successful treatment of ventricular fibrillation in the field. Platoons with and without the algorithms served identical areas of the city, did not differ in response times, and were treated similarly with regard to continuing education during the study period. Paramedics who received the algorithms were encouraged, but not required, to use them. Platoons using the algorithms experienced an increase in their ventricular fibrillation patient survival rates from 10.6% to 14.5%; those platoons not using the algorithms had a decrease in patient survival rates from 11.8% to 7.0% (P = 0.0732). There was no statistically significant difference in the paramedics' scores on arrhythmia recognition and management tests given before and after use of the algorithms. Only 39% of the paramedics used the algorithms during actual patient care, but 83% used them as a study guide or for reference between runs. The data suggest that algorithm use may minimize the rate of knowledge and skill decay.

Interobserver and intraobserver reliability in the collection of emergency medical services data.

The collection of data by abstraction from patient records is a widely used method of research, evaluation, and registry. Since valid conclusions depend on the accuracy of the abstracted data, it is essential to examine the abstracting procedures. In this paper, we report on a study of patient data abstracted from emergency department records by nurses trained by project personnel. Twenty-five charts were selected at each of five hospitals. To test interobserver reliability, the nurses were asked to abstract all of the charts at each hospital; to test intraobserver reliability, four of the nurses each reabstracted a set of charts. The results show that even with highly trained, well motivated abstractors, there are considerable differences in the accuracy with which the variables are abstracted. Disposition from the hospital, quantitative vital signs, and blood gas values tend to be abstracted with higher reliability; whereas variables requiring judgment, such as character of vital signs or history of disease, tend to have low reliability. To improve the quality of abstracted data, we propose improved retrieval methods for hospital records, monitoring of data collection procedures, cooperation of all medical personnel providing the raw data, and careful selection of variables.

Prehospital cardiac care: illusion of consensus.

To judge standard practice for managing arrhythmias, what an EMT should be able to do in the field, drugs of choice, the success of EMT training, and the quality of EMT performance, clinical algorithms were developed. Branching logic, forcing yes/no decisions and delineating actions for all contingencies helped formalize and systematize EMT management of urgent and emergency cases. The algorithm set was sent to 19 consultants for review of content, sequence, drug dosage, and drug usage. The results indicated lack of consensus on appropriate prehospital cardiac care, but the approval of the algorithm approach.

Emergency medical technician-paramedic training.

With a nationally standardized emergency medical technician-paramedic training program soon to be adopted, certain factors in the planning of training programs should be emphasized. (1) The facilities should provide an opportunity for the paramedics to gain clinical experience in intensive care units and emergency departments. Teaching must be appropriate to the students' educational background. (2) The course content should include advanced life-support. (3) Full-time and part-time programs must be developed, possibly using a modular format. (4) The operating procedure should conform to local medical and legal practice. (5) Mechanisms for evaluation and recertification must be developed. (6) Continuing education, as important or more important than the original training, should be included in program planning.

Auditing the quality of care in emergency departments.

A methodology for evaluating the quality of emergency department care in the form of a retrospective process audit for emergent and urgent cases was developed and tested in the Philadelphia General Hospital Emergency Department. A physician panel develped criteria against which the management of six "chief complaints," as indicated on the medical record, was measured. Then nonphysician auditors examined records retrospectively for a three-week period, covering every day and shift for a total sample of 389 cases. The physician panel made an implicit review of those records that varied from the criteria. The results of the review in four diagnostic areas showed that for chest pain 51% (36) did not meet the provisional standards; for abdominal pain 35% (35) did not; for wounds 51% (51) did not, and for sore throats 43% (22) did not. These results were presented to the ED staff and charts were re-audited after one month. The results of this second audit are being tabulated though preliminary findings indicate an improvement in the percentage of cases meeting the criteria.